5 doses of Oxycodone per patient. After elimination, 270 patients underwent appendectomy and 3 patients (1.1%) received opiate prescriptions for an average 0.05 doses of Oxycodone per patient. Patients contacted by phone expressed no pain relief issues and no patients later needed opiates. CONCLUSION Using a step-wise process we have eliminated the use of opiates for post-discharge pain in children undergoing laparoscopic appendectomy. This intervention has resulted in the elimination of 4,035 doses of Oxycodone from the community over the study period while ensuring that postoperative pain control has been adequate. The United States is now in the grip of pandemic. Surgical services have been severely disrupted and will be for at least several months. The pandemic poses unprecedented challenges to surgical residency and fellowship programs. In turn, there are unprecedented challenges to the process of accrediting those programs. This article delineates some of those challenges and the responses to them which are known, to date. BACKGROUND The objective of this study was to determine the effects of using the Surgical Risk Preoperative Assessment System (SURPAS) on patient satisfaction and surgeon efficiency in the surgical informed consent process as compared to surgeons' "usual" consent process. STUDY DESIGN Patient perception of the consent process was assessed via survey in two cohorts 10 surgeons in different specialties used their "usual" consent process for 10 patients; these surgeons were then taught to use SURPAS and employed it during the informed consent process of 10 additional patients. The data were compared using Fisher's exact test and the Cochran-Mantel-Haenszel test. RESULTS 100 patients underwent the "usual" consent process (USUAL) and 93 underwent SURPAS-guided consent (SURPAS). 82% of SURPAS were "very satisfied" and 18% were "satisfied" with risk discussion vs. 16% and 72% of USUAL. 75.3% of SURPAS reported the risk discussion made them "more comfortable" with surgery vs. 19% of USUAL. 90.3% of SURPAS reported "somewhat" or "greatly decreased" anxiety vs. 20% of USUAL. All p-values were less then 0.0001. 97.9% of SURPAS patients reported "enough time spent discussing risks" vs. 72.0% of USUAL. CONCLUSION The SURPAS tool improved the informed consent process for patients compared to the "usual" consent process, in terms of patient satisfaction, making patients feel more comfortable and less anxious about their impending operations. Providers should consider integrating the SURPAS tool into their preoperative consent process. BACKGROUND A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared to open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis (NP). We sought to determine if transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage (PD), endoscopic transgastric necrosectomy (ETN), video-assisted retroperitoneal debridement (VARD), sinus tract endoscopic necrosectomy (STE), or a combination of techniques, with selective use of OSN. STUDY DESIGN Observational cohort study with retrospective comparison at a single tertiary referral center (2006-2019). 88 patients were treated with OSN and 91 were treated with a MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary outcome was 90-day mortality. RESULTS There was no difference in baseline characteristics. 90-day mortality was 2% with MIS compared to 10% with OSN (p=0.03). One-year mortality was 3% with MIS compared to 15% with OSN (p=0.012). The rate of organ failure was lower with MIS (30% vs 45%, p=0.029), but there was a higher bleeding rate (19% vs 9%) (p=0.064). In the MIS group, 9% were treated with PD, 32% with ETN, 8% with VARD, 15% with STE, and 27% with a combination of techniques. CONCLUSION Adoption of a multidisciplinary MIS-based approach to NP resulted in a 5-fold decrease in mortality compared to OSN. BACKGROUND Hepatitis E virus (HEV) is a common cause of viral hepatitis worldwide. Previously considered a disease of the developing world, it is increasingly recognised that locally acquired HEV infection is common in industrialised countries. OBJECTIVES To highlight the changing epidemiology of HEV infection, particularly in the developed world, and inform clinicians of the diverse clinical presentations and extra-hepatic complications associated with the virus. SOURCES References for this review were identified through searches of MEDLINE/PubMed, and Google Scholar, up to January 2020. Searches were restricted to articles published in English. CONTENT Hepatitis E virus is an under-recognised, emerging pathogen with important implications for public health in both the developing and developed world. The number of cases reported in resource-rich settings is increasing, in part due to improved case ascertainment but also as a result of increased incidence in some countries. The reasons behind these epidemiolo annual routine screening. OBJECTIVES In vitro models showing synergism between polymyxins and carbapenems support combination treatment for carbapenem-resistant Gram-negative (CRGN) infections. We tested the association between the presence of in vitro synergism and clinical outcomes in patients treated with colistin plus meropenem. METHODS This was a secondary analysis of AIDA, a randomized controlled trial comparing colistin to colistin-meropenem for severe CRGN infections. We tested in vitro synergism using a checkerboard assay. Based on the Fractional Inhibitory Concentration (ΣFIC) index for each colistin-meropenem combination, we categorized results as synergistic, antagonistic, or additive/indifferent. The primary outcome was clinical failure at 14&nbsp;days. Secondary outcomes were 14- and 28-day mortality and microbiological failure. https://www.selleckchem.com/products/at-406.html RESULTS The sample included 171 patients with infections caused by carbapenem-resistant A. baumannii (n=131), Enterobacteriaceae (n=37) and P. aeuruginosa (n=3). In vitro testing showed synergism for 73 isolates, antagonism for 20, and additivism/indifference for 78. In patients who received any colistin plus meropenem, clinical failure at 14&nbsp;days was 59/78 (75.6%) in the additivism/indifference group (reference category), 54/73 (74.0%) in the synergism group (adjusted odds ratio [aOR] 0.76, 95% CI 0.31-1.83), and 11/20 (55%) in the antagonism group (aOR 0.77, 95% CI 0.22-2.73). There was no significant difference between groups for any secondary outcome. Comparing the synergism group to patients treated with colistin monotherapy, synergism was not protective against 14-day clinical failure (aOR 0.52, 95% CI 0.26-1.04) nor 14-day mortality (aOR1.09, 95% CI 0.60-1.96). CONCLUSIONS In vitro synergism between colistin and meropenem via checkerboard method did not translate into clinical benefit.